Monday, August 18, 2014
July 28, 2014
To: Sylvia Burwell, ￼Secretary of Health and Human Services
From: Over 300 patient advocacy groups
Based on reports of enrollee experiences during the first year of
Marketplace implementation, we have identified a number of concerns.
These include discriminatory benefit designs that limit access, such as
restrictive formularies and inadequate provider networks; high
cost-sharing; and a lack of plan transparency that may deprive consumers
of information that is essential to making informed enrollment choices.
Due to the manner in which Essential Health Benefits (EHBs) are defined
for plan years 2014 and 2015, select plans do not include all the
medications that enrollees may be prescribed to address their health
care needs. Plans are further restricting access to care by imposing
utilization management policies, such as prior authorization, step
therapy and quantity limits. Tying plan formulary requirements to the
number of drugs in each class in the state benchmark has resulted in
some plans not covering critical medications, including combination
therapies. Additionally, there is no requirement for plans to cover new
medications and plans can remove medications during the plan year as
long as the plan continues to meet the state's benchmark requirements.
Narrow provider networks and a lack of access to specialists are also
negatively impacting access to quality care for enrollees.
These design elements appear to affect certain patient populations
disproportionately – many of the same populations that were subject to
pre-existing condition restrictions prior to ACA implementation.
Despite enrollee out-of-pocket limits that are included in the ACA and
reduced cost-sharing for people with very low income levels, some plans
are placing extremely high co- insurance on lifesaving medications, and
putting all or most medications in a given class, including generics, on
the highest cost tier. This creates an undue burden on enrollees who
rely on these medications. Unlike employer-sponsored plans, where
enrollees usually experience reasonable co- pays, enrollees in the
Marketplace are being subject to plans that impose 30%, 40% and even 50%
co-insurance per prescription. Such high co-insurance is shocking
enrollees and will lead to reduced medication adherence and medical
complications as people are unable to afford to begin or stay on
medications. Some plans are also imposing high deductibles for
prescription medications and high cost-sharing for accessing specialists.
We believe these practices are highly discriminatory against patients
with chronic health conditions and may, in fact, violate the ACA
Transparency and Uniformity:
Individuals must have access to easy-to-understand, detailed information
about plan benefits, formularies, provider networks, and the costs of
medications and services. Unfortunately, individuals cannot access this
information easily through an interactive web tool such as a plan finder
or benefit calculator that matches an individual's prescriptions and
provider needs with appropriate plans (such as the one utilized by the
Medicare Part D program). Most troubling is the practice of requiring
co-insurance without information for an individual to understand what
their actual cost-sharing will be. Transparent, easy-to-navigate
grievances and appeals processes are needed, along with special
enrollment procedures when patients lose access to a medication due to
formulary changes during a plan year.
Comment by Don McCanne
In spite of regulations defining the essential health benefits to be
covered, actuarial values of the health plans, and adequacy of plan
descriptions, the private insurers continue to use deceit in
implementing these regulations to avoid enrolling individuals with
greater health care needs. Even if some of the current deceptions are
patched, they will always use the marketplace tool of innovation in
order to advantage themselves over patients.
Though the government may try to revise regulations as problems arise,
no regulation can ever alter the innate amorality of the industry - no,
make that immorality. The private insurers need to be replaced with a
single payer national health program.
at 2:40 PM